HOME HEALTH CERTIFICATION AND PLAN OF CARE 1. Patients HI Claim No. 2. Start of Care Date 3. Certification Period 4. Medical 5. Provider # Record # From: To: 6. Patient’s Name and Address 7. Provider’s Name, Address and Telephone Number 8. Date of Birth: 9. M F 11. ICD-9-CM Principal Diagnosis Date 10. Medications: Dose, frequency/Route (N)ew (C)hanged 12. ICD-9-CM Surgical Procedures Date 13. ICD-9-CM Other Pertinent Diagnoses Date 14. DME and Supplies 15. Safety Measures: 16. Nutritional Req. 17. Allergies: 18.A Functional Limitations 18.B Activities Permitted 1. Amputation 5.Paralysis 9. Legally Blind 1. Complete Bedrest 6. Partial Weight Bearing A Wheelchair 2. B/B Incont. 6. Endurance 2. Bedrest BRP A Dyspnea w/ min. Ex. 7. Independent at home B Walker 3. Contracture 7. Ambulation B Other(specify) 3. Up as Tolerated 8. Crutches C No Restriction 4. Hearing 8. Speech 4. Transfer bed/chair 9. Cane D Other 5. Exercises Prescribed 19. Mental Status: 1.Oriented 3. Forgetful 5.Disoriented 7.Agitated 2.Comatose 4 .Depressed 6.Lethargic 8.Other 20. Prognosis: 1.Poor 2.Guarded 3.Fair 4.Good 5.Excellent 21. Orders for Discipline and Treatments (SpecifyAmount/Frequency/Duration) 22. Goals/Rehabilitation Potential/Discharge Plans 23. Nurse’s Signature and Date 25. Date HHA Received Signed POT 24. Physician’s Name and Address 26. I certify that this patient is confined to his/her home and needs intermittent skilled nursing care, physical therapy and or speech therapy or continues to need occupational therapy. The patient is under my care and I have authorized the services on this plan of care and will periodically review the plan 27. Attending Physician’s Signature and Date Signed 28. Anyone who misrepresents, falsifies, or conceals essential information required for payment of Federal funds may be subject to fine, imprisonment, or civil penalty under applicable Federal laws.